Personal Coverage - The G.F. Hoch Company

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Homeowner Quote

Required Fields are noted with an asterisk (*).
** Note: At least one phone number is required.

Homeowner Quote pg 1 of 2

* Your name (First, Mi, Last):

Social Security Number:

(no dashes)

Date of Birth:

(mm/dd/yyyy)

* Address:

* City:

* State/Zip:

** Daytime telephone:

** Mobile phone :

Email address:

Name of Employer:

Job Title/Position:

How would you like your quote delivered?:

Via phone call Via e-mail

Current coverage company:

Exp. date

Amount of Insurance Desired:

What is the value of your home?:
What is the value of betterments/improvements?:
Liability limit:
Medical payments:

Property Information

What is the construction type of your home?
In what year was your home built?
In what county/township are you located?
Distance to the nearest fire hydrant?
What kind of pets do you have?
How many stories does your home have?
What is the square footage of your home?
Do you have an attached garage?	yes no
Is your basement finished?	yes no
Do you use a wood burner?	yes no
Do you have a home security system installed?	yes no
If so, is your alarm system local or central?	local central
Do you have a swimming pool?	yes no
If so, is your pool fenced in?	yes no

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